Ymca Storer Camps - Oee Youth Health Form (Page 3 of 3) in pdf

Student Name:________________________________________________

School:_______________________________________________________

What Else Would You Like Us To Know? Let us know any information about your camper’s health that may have been neglected on this form.

Any information that has an impact on your student’s ability to fully participate in our program is appreciated. Attach additional information if needed.

Parent/Guardian Authorization

The information contained in this form is correct, as far as I know, and the child herein described has permission to engage in all camp activities except as

noted. I understand that health/accident insurance coverage is the responsibility of the parent/guardian. I hereby give permission to YMCA Storer Camps to

secure emergency medical, routine medical, surgical treatment, and non-surgical care for the child named on this form, while at camp. I also understand that

the parent/guardian is fully responsible for the camper’s transportation if he/she is dismissed for disciplinary, behavior or medical reasons. I absolve the

YMCA of Greater Toledo/Storer Camps and all of its employees of any and all liability, financial and/or otherwise arising from administration of medication to

my child under the terms of this release. YMCA Storer Camps is not responsible for payment of any medical expenses incurred during participation at camp.

In consideration for being allowed to participate in the YMCA’s programs, I agree to assume the risk of such activities and programs, and I further

agree to hold harmless the YMCA of Greater Toledo, it’s officers, employees and representatives from any and all claims, suits, losses, or related causes

of action for damages, including, but not limited to, such claims that may result from injury or death, accident or otherwise, during or arising in any way

from the activities. I grant permission for me or my child to participate in all planned camp activities including out of camp trips by van or bus, hiking

or horseback riding. The YMCA is not responsible for lost, stolen or damaged personal articles. I also authorize the YMCA to have and use

photographs, slides or video tapes of me, my child, or my family as may be needed for its public relations programs. I acknowledge that this General

Release of Liability and Authorization for Treatment of the YMCA is binding on me personally and on my heirs, personal representatives, successors and

assigns.

Limited Purpose Power of Attorney: Consent to Treatment of Minor (Must be signed by parents or legal guardians)

By signature(s) below, the undersigned appoints______________________________________________ (School Name), to act alone, or delegate to another person, the power to

consent on our behalf to all emergency treatment and/or medical care (except elective surgery) of (child’s name) _____________________________________ determined to be

necessary or desirable by our child’s attending physician at the hospital. This Power of Attorney shall continue through the participant’s stay at camp, or until

revoked by the undersigned, whichever is earlier. Physicians or the hospital’s medical staff may assume and rely on this authorization being current and in

effect during such period unless notified otherwise. The undersigned certify that they read this Power of Attorney (or had it read to them), that they

understand this Power of Attorney, and sign it voluntarily. This agreement will be enforced in accordance with the law of the State of Michigan.

Parent/Guardian Signature: ________________________________________ Date: _______________

Health Office Use Only

Date

Time

CHO

Notes

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